Act now to avoid penalties as claims-based MIPS reporting ends

By Stephen Besch, Director of Clinical Quality Reporting

The rewards and risks of MIPS continue to grow, with a range of plus or minus 7 percent for 2019 reporting. The increased penalties, combined with new restrictions on claims-based reporting, make an up-to-date MIPS reporting strategy more important than ever.

As of 2019, CMS is allowing only “small groups” to continue submitting MIPS quality data through claims-based reporting. Small groups are defined as those with Tax ID Numbers (TINs) comprising 15 or fewer clinicians. If more than 15 clinicians are billing under your TIN and you were relying on claims-based data submission to meet your 2019 MIPS quality reporting obligations, you must find an alternate quality data submission method now. If you don’t, you could see a reduction of up to 7 percent in your Medicare reimbursements.

While claims-based reporting of MIPS quality measures frequently suffered from reliability issues, it was a cheap and relatively easy method of sending performance data for many years. Healthcare groups simply sent designated CPT2 or G codes to CMS on the same claim as the billable encounter that required reporting of a given quality measure, and the reporting responsibilities were met.

Many clinicians have depended on claims-based submission for so long that they may have taken their eyes off the road. They expect to achieve successful MIPS reporting for 2019 via the route they followed so many times before. In doing so, they have failed to notice this new sharp curve that could mean their familiar path now leads to submission failure and financial loss.

calculator and papers on deck

What are the options?

If you find yourself in this predicament, what are some alternatives to claims-based reporting that might salvage your MIPS participation and protect your revenue?

CMS Web Interface

This is a clunky and labor-intensive method that most consider a last resort. It doesn’t lend itself to automation, so performance data on nearly a dozen different quality measures must be collected manually for hundreds of patients. Additionally, participants are required to opt-in to this reporting option with CMS during Q2 of the relevant program year (i.e., to use the Web Interface submission option for 2019 quality data, you would need to have opted in during Q2 of 2019).

All things considered, while it might be an option for 2020, CMS Web Interface submission won’t offer you much help right now.


This method can be convenient if you’re using a CEHRT-compliant system and you’re employed directly by the hospital that owns it. Unfortunately, many contracted physician services don’t have the EHR access level required to successfully track and submit quality measures through that system. Even if they do, the hospital has no financial incentive to fund MIPS data submissions for contracted clinicians.

Inpatient clinicians are typically exempt from reporting the EHR component of MIPS due to their lack of access to or control over the EHR system in use. That’s why this method of quality data submission is generally not available to them.

Qualified Registries and Qualified Clinical Data Registries (QCDRs)

These CMS-approved vendors retrospectively analyze performance for the entire year and then submit assessments directly to CMS in Q1 of the following year. The timetable for their analysis and submission services can make registries and QCDRs viable methods of capturing and transmitting quality data even when the opportunity to report through other methods may have already passed. Registry submission offers a host of additional strategic advantages over claims-based submission as well: higher average scores, increased data accuracy, group submissions and more.

Future developments and strategies

CMS has expressed interest in phasing out claims-based submission for several years. The new reporting restrictions for 2019 are likely just the first step in eliminating this option from the program entirely. But while small groups may lose the claims-based reporting option in the near future, it’s certainly more critical now for groups larger than 15 clinicians. To ensure continued success within the MIPS program, it’s crucial to establish a relationship with an experienced Qualified Registry.

For example, Ingenious Med has been a Qualified Registry since 2010, consistently maintaining a 100 percent submission success rate. We also offer informative webinars to healthcare organizations each December to review important updates to the MIPS reporting requirements in the coming year and highlight new strategies to optimize success.

As claims-based reporting is being phased out, the MIPS program will continue to evolve in other ways as well. To ensure you’re aware of critical changes to the program in the future, watch our blog for more educational installments and details about our upcoming webinars.